Background
The term moral injury (MI) has increasingly appeared in the research literature since it was first coined by psychiatrist Johnathan Shay in the early 1990s [
1]. To date, there are many definitions of MI that have been proposed [
2]. More recently, Shay suggested a definition made up of three components: “(1) betrayal of ‘what’s right’ (2) by someone who holds legitimate authority (3) in a high stakes situation” [
3]. MI has been found to be present in a wide range of populations experiencing severe trauma, including military personnel, war veterans, first responders, rape victims, and others [
4,
5]. At least one qualitative study has reported that the term moral injury is useful for exploring medical students’ experience in emergency medicine settings [
6]. A study of refuges in Switzerland found that MI accounted for 16% of the variance in post-tramatic stress disorder (PTSD) symptoms [
7]. Papazoglou found that MI was frequently experienced by police officers after suffering repeated trauma [
8].
Until 2013, there were no measures to assess MI as currently understood. Since then, several have emerged to assess the presence of MI among military populations, including two types of assessment tools: (1) those that measure both morally injurious events and MI symptoms, and (2) those that measure MI symptoms only. Measures in the first category include the 9-item Moral Injury Events Scale (MIES) developed Nash and colleagues in diverse military samples [
9,
10]. Several years later, the 20-item Moral Injury Questionnaire was developed by Currier and colleagues, again assessing both morally-injurious events and symptoms [
11]. The first measure to assess MI symptoms only was the 45-item Moral Injury Symptoms Scale-Military Version-Long Form (MISS-M-LF) [
12], followed soon by the publication of the 17-item Expressions of Moral Injury Scale-Military Version (EMIS-M) by Currier and colleagues [
13]. The MISS-M-LF was then shorted by Koenig and colleagues to a 10-item version (MISS-M-SF) [
14], and this was later followed by a 4-item short version of the EMIS-M [
15]. Those measures were all developed in samples of active duty military or war veterans.
These scales have largely followed the definitions by Shay [
3] and Bret Litz et al. [
16] that focused on MI symptoms acquired during combat, such as feelings of shame, grief, meaninglessness, and remorse from having violated core moral beliefs [
17]. Symptoms relate to what one has done (killed combatants or innocents, dismembered bodies, maltreated others, or deserted comrades during battle), what one has failed to do (protected innocents or prevented the death of fellow soldiers), and what one has observed others do or fail to do [
18]. MI symptoms may also involve intense feelings of betrayal by those in authority, either in or outside of the military, and include religious or spiritual struggles or a complete loss of religious faith resulting from experiences during wartime [
17].
Recently, MI among physicians and other health professionals has attracted attention in the mainstream literature, particularly when discussing issues related to burnout [
19]. Clinicians may experience MI when they feel their ability to deliver care is compromised by the systems (e.g., insurance, reimbursement, electronic health record) being implemented in hospitals, clinics, and medical practices [
20]. During the COVID-19 pandemic, physicians in China have faced difficult ethical/moral decisions given the enormous influx of patients with life-threatening infections and limitations in available ventilators, personal protective equipment, and lifesaving medications. These physicians (and nurses) have had to play God in making decisions on who gets treatment and who does not, as well as having to deal with exposure to the coronavirus themselves and the risk this poses to their families and patients [
21,
22]. As a result, health professionals have been stigmatized as vectors of contagion, resulting in their assault, abuse, and isolation during the COVID-19 pandemic, just as they had been during the SARS pandemic [
23]. This situation has caused many health professionals to feel a sense of helplessness, shame, and guilt, as hundreds of patients die every day [
24]. Unfortunately, until now there have been no psychometrically reliable and valid scales to measure MI symptoms in healthcare professionals.
The purpose of this study is to examine the psychometric properties of the 10-item Moral Injury Symptoms Scale-Health Professional (MISS-HP) developed by Koenig and colleagues [
25], which is a modified version of the MISS-M-SF developed in military personnel [
13] to make it applicable to healthcare professionals. This measure assesses 10 dimensions of the moral injury: betrayal, guilt, shame, moral concerns, loss of trust, loss of meaning, difficulty forgiving, self-condemnation, religious struggle, and loss of religious/spiritual faith.
Discussion
To our knowledge, this is the first study to examine the psychometric properties of the MISS-HP, a short but comprehensive measure of moral injury symptoms, in a large sample of health professionals. Unlike other measures of MI, the MISS-HP is unique in that it assesses both psychological and religious/spiritual dimensions of MI. The results indicated that the MISS-HP is a reliable and valid measure of MI in both nurses and physicians. The findings provide primary evidence supporting the use of this tool for assessing symptoms of MI as part of health promotion programs for health professionals in China. The MISS-HP also fills an important gap in research that examines the prevalence, correlates, and health consequences of MI in nurses and physicians.
The internal consistency of the MISS-HP (alpha = 0.70 for physicians and 0.71 for nurses) is acceptable, as is the test-retest reliability (ICC = 0.77 in physicians). With regard to validity, the MISS-HP has acceptable convergent validity with another established measure of MI, the EMIS-SF (r = 0.45 for physicians and r = 0.43 for nurses). Correlations with common mental conditions (depression and anxiety), well-being, and burnout measures are as robust with the MISS-HP as with the EMIS-SF.
Known groups validity supports using the MISS-HP to identify MI among those suffering from potentially morally injurious events such as being assaulted by patients or relatives. This finding is partly supported by a study of military veteran family members, which found that such violence inflicts damage to moral belief systems and causes a loss of trus t [
41]. Many physicians have been killed and injured during the past decade in China [
42]. Moral injury can be the consequence of unexpected violence from patients or their relatives, giving rise to feelings of betrayal in nurses and physicians by the very population they are risking their lives to help (especially during this COVID-19 pandemic) [
16].
Construct validity of the MISS-HP was established using exploratory factor analysis (EFA), which was then verified by CFA. Factor analysis indicated a three-dimensional structure for the MISS-HP, explaining 59% of the total variance. This finding is consistent with the work of Griffin and colleagues [
2] who suggested at least two interrelated MI symptom dimensions, self-directed outcomes (e.g., thoughts/feelings of responsibility for occurrence of moral violations such as shame or viewing oneself as unlovable or unforgivable) and other-directed outcomes (e.g., thoughts/feelings associated with being a victim of others’ morally transgressive acts). Add to this the religious/spiritual dimension of MI involving struggle and loss of faith.
Limitations
Several aspects of the present study limit the generalizability of these findings, thereby influencing both research and clinical implications. First, we assessed the MISS-HP in a single cross-sectional study involving a nonrandom sample of Chinese health professionals which did not include those in practice for less than 2 years (who may be at even greater risk if MI given their lack of experience). The the findings here require cautious generalization to service members in other areas of the China and to health professionals outside of China. Second, although, a standard translation procedure was used to create a Chinese version of the MISS-HP, cultural differences between China and the Western society (where the scale as initially developed and designed) may have affected the final result (both the translation and the meaning of items). Third, despite the consistent findings showed in nurses and physicians, test-retest relieability was conducted only in physicians, which may lead to uncertainty for the scale’s use in nurses. Fourth, the internal reliability of the MISS-HP was borderline but acceptable in both nurses and physicians (alpha = 0.70 or higher). Fifth, other morally injurious events besides workplace violence need to be assessed in future studies. Finally, like all self-report measures, the accuracy of responses cannot be guaranteed where external factors may influence the report of symptoms (even though the survey was anonymous in nature).
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